HEALTH INSURANCE PREMIUM & COST SHARING ASSISTANCE

Transcription

1 HEALTH INSURANCE PREMIUM & COST SHARING ASSISTANCE I. DEFINITION OF SERVICE Provision of Health Insurance Premium and Cost-sharing Assistance that provides a cost -effective alternative to ADAP by: Purchasing health insurance that provides comprehensive primary care and pharmacy benefits for low income clients that provide a full range of HIV medications Paying co-pay (including co-pays for prescription eyewear for conditions related to HIV infection) and deductibles on behalf of the client Providing funds to contribute to a client s Medicare Part D true out-of-pocked (TrOOP) costs (Allowable use of Ryan White funds as of January 1, 2011 as specified in the Affordable Care Act.) These short term payments must be carefully monitored to assure limited amounts, limited use, and for limited periods of time. II. DESCRIPTION OF SERVICE SERVICE PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS Provision of Health Insurance Documentation of the following: 1. Conduct an annual cost benefit analysis Ryan White funds Premium and Cost-sharing 1. An annual cost-benefit analysis illustrating the (if not done by the Grantee) that are not used for any Assistance that provides a costeffective greater benefit in purchasing public or private addresses the noted criteria cost associated with alternative to ADAP by: health insurance, pharmacy benefits, co-pays 2. Where premiums are covered by Ryan liability risk pools Purchasing health insurance and/or deductibles for eligible low income clients, White funds, provide proof that the or Social Security that provides comprehensive compared to the costs of having the client in the insurance policy provides primary care and pharmacy ADAP program comprehensive primary care and benefits for low income clients 2. Where funds are covering premiums, formulary with a full range of HIV that provide a full range of HIV documentation that the insurance plan purchased medications to clients medications provides comprehensive primary care and a full 3. Maintain proof of low-income status Paying co-pays (including copays for prescription eyewear 3. Where funds are used to cover co-pays for 4. Provide documentation that range of HIV medications within client s records for conditions related to HIV prescription eyewear, documentation including a demonstrates that funds were not used infection) and deductibles on physician s written statement that the eye to cover costs of liability risk pools, or behalf of the client condition is related to HIV infection social security Providing funds to contribute 4. Assurance that any cost associated with liability 5. Coordinate with CMS, including to a client s Medicare Part D risk pools is not being funded by Ryan White entering into appropriate agreements, true out-of-pocket (TrOOP) 5. Assurance that Ryan White funds are not being to ensure that funds are appropriately costs* used to cover costs associated with Social Security included in TrOOP or donut hole costs *Allowable use of RW funds as of 6. Clients low income status as defined by the 6. When funds are used to cover co-pays January 1, 2011 as specified in the EMA or State Ryan White Program is clearly for prescription eyewear, provide a Affordable Care Act indicated in the clients files for eligibility physician s written statement that the eye condition is related to HIV infection Prepared by Germane Solutions QI Revised April Page

2 III. NATIONAL FISCAL MONITORING STANDARDS (HRSA issued April 2013): SERVICE PERFORMANCE MEASURE/METHOD MONITORING STANDARDS LIMITATIONS SECTION D: Imposition & Assessment of Client Charges 1. Ensure grantee and subgrantee policies and procedures require a publicly posted schedule of charges (e.g. sliding fee scale) to clients for services, which may include a documented decision to impose only a nominal charge 2. No charges imposed on clients with incomes below 100% of the Federal Poverty Level (FPL) 3. Charges to clients with incomes greater than 100% of poverty are determined by the schedule of charges. Annual limitations on amounts of charge (i.e. cap on charges) for RW services are based on the percent of client s annual income, as follows: 5% for clients with incomes between 100% and 200% of FPL 7% for clients with incomes between 200% and 300% of FPL 10% for clients with incomes greater than 300% of FPL Review of subgrantee policies and procedures, to determine: Existence of a provider policy for a schedule of charges. A publicly posted schedule of charges based on current Federal Poverty Level (FPL) including cap on charges Client eligibility for imposition of charges based on the schedule Track client charges mad and payments received How accounting systems are used for tracking charges, payments, and adjustments Review of provider policy for schedule of charges to ensure clients with incomes below 100% of the FPL are not charged for services Review of policy for schedule of charges and cap on charges Review of accounting system for tracking patient charges and payments Review of charges and payments to ensure that charges are discontinued once the client has reached his/her annual cap. Establish, document and have available for review: Policy for a schedule of charges Current schedule of charges Client eligibility determination in client records Fees charged by the provider and the payments made to that provider by clients Process for obtaining, and documenting client charges and payments through an accounting system, manual or electronic Document that: Policy for schedule of charges does not allow clients below 100% of FPL to be charged for services Personnel are aware of and consistently following the policy for schedule of charges. Policy for schedule of charges must be publicly posted. Establish and maintain a schedule of charges and policy that includes a cap on charges and the following: Responsibility for client eligibility determination to establish individual fees and caps Tracking of Part A charges or medical expenses inclusive of enrollment fees, deductibles, copayments, etc. A process for alerting the billing system that the client has reached the cap and should not be further charged for the remainder of the year Personnel are aware and consistently following the policy for schedule of charges and cap on charges. Prepared by Germane Solutions QI Revised April P age

3 IV. HIPCSA SERVICE COMPONENTS Program Outcome: Medically related co-payments for health insurance Indicator: 100% of clients access HIV-related PMC or HIV medications supported by co-payment assistance. Service Unit(s): Number of successful co-payments for: Billed physician visits HIV medications Standard of Care Outcome Measure Numerator Denominator Data Source Goal/Benchmark I. Structure Provider agency has clearly stated, written guidelines that list all criteria, including allowable extenuating circumstances, used to determine if a client is eligible for health insurance premium or cost sharing assistance. Agency provides comprehensive orientation for new staff members to ensure that staff is fully trained to implement the written guidelines. Services are made available to all individuals who meet HIPCSA program eligibility requirements. II. Process Agency follows written guidelines, without exception, for all requests. III. Outcome Provider agency pays routine requests for payment within 14 days. Provider agency pays emergency requests for. Agency sends notice to case manager that payment has been made within 5 days after check is sent. Agency has documented criteria to determine eligibility for health insurance premium and cost sharing assistance. Client charts document adherence to guidelines Provider assesses and documents client eligibility for alternative coverage of health insurance premium (e.g. Part B) or cost sharing (compassionate care) prior to Ryan White Part A assistance. Charts document adherence to written guidelines Clients receive payment within 14 days Client receive emergency Client case managers receive notice of payment within 5 days after check is sent and is documented in chart Number of agencies with guidelines Number of new staff with documented orientation Number of charts documenting assistance Number of charts follow guidelines Number of clients receive payment within 14 days Number of clients receive emergency Number of client case managers receive notice of payment within 5 days of check sent Number of contracted agencies for HIPCSA Prepared by Germane Solutions QI Revised April P age Agency files Policy & Procedure Manual 100% of agencies have written guidelines for health insurance premiums and/or cost sharing assistance Number of new staff Personnel file 100% of new staff receive orientation on guidelines Number of clients Client chart 100% of charts documents client eligibility for Part A assistance Number of clients Client chart 100% charts document adherence to written guidelines Number of clients Client chart 100% of client charts document payment within 14 days. Number of clients Client chart 100% of client charts document emergency Number of clients Client chart 90% of client case managers receive notice of payment within 5 days after check is sent

4 IV. DATA REPORTING Part A service providers are responsible for documenting and keeping accurate records of Ryan White Program Data/Client information, units of service, and client health outcomes. Reporting units of service are a component of each agency s approved workplan. Please refer to the most current workplan, including any amendments, for guidance regarding units of service. Summaries of service statistics by priority will be made available to the Planning Council by the Grantee for priority setting, resource allocation and evaluation purposes. Prepared by Germane Solutions QI Revised April P age

5 Assistance Service Standards Health Insurance Premium & Cost Sharing STRUCTURE ( WHO ) Hlth Insurance Tool Staff & Charting & Monitoring Process 1 Agency Licensure, Certification 2 Annual Cost- benefit analysis (if not done by Grantee) Staff Education Documentation of Staff Education on HIPCSA guidelines Recordkeeping Requirements Chart is properly stored & secure; chart is clearly organized; entries legible Eligibility Guidelines Chart shows eligibility guidelines have been followed/assessed every 6 mos Sliding Fee Scale Providers maintain current sliding fee scale in accordance with HRSA mandate Sevices are Available Services are available to those who meet guidelines Client Demographics Age, ethnicity, gender, risk/exposure documented PROCESS ( How ) Collaboration with CADAP Letter of collaboration between CADAP and HIPCSA Agency 10 Alternate Funding Sources Provider assists in seeking alternate funding sources 11 Detail of HIPCSA Services Rendered 1. Purchasing health insurance for comprehensive primary care and pharmacy benefits for low income clients with a full range of HIV medications 2. Paying co- pay (including co- pays for prescription eyewear for conditions related to HIV infection) and deductibles on behalf of the client 3. Providing funds to contribute to a client's Medicare Part D true out- of- pocket (TrOOP) cost OUTCOME ("What Impact") Outcome Payments Routine requests for payment are made within 14 days Emergency Requests Emergency Requests for payment are made within 48 hours Retention in HIV Medical Care Client remains in HIV medical care (continuous care) as result of HIPCSA intervention Prepared by Germane Solutions QI Revised April P age